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(ii) vasodilatation, with increase in arteriolar and venous capacitance as a result of camp-mediated increase in uptake of calcium how to use cialis 10mg and decrease in calcium available for contraction. And (iii) increased lusitropy, or improved relaxation properties during diastole. Indications for use include low cardiac output with myocardial dysfunction and elevated systemic vascular resistance (svr) not accompanied by severe hypotension. Side effects have been minimal and are typically the need for volume infusions (5-1 0 ml/kg) following loading dose administration. See appendix a for dosing information. The use of phosphodiesterase inhibitors after cardiac surgery in the pediatric patient population has been shown to increase cardiac index and decrease svr without a significant increase in heart rate. Phosphodiesterase inhibitors are the second-line drug (after dopamine) in the treatment oflow cardiac output in neonates, infants, and children following cardiopulmonary bypass in our institution. 2. Other vasodilators improve low cardiac output principally by decreasing impedance to ventricular ejection. These effects are especially helpful after cardiac surgery in children and in adults when svr is particularly elevated. Sodium nitroprusside is the most widely used afterload reducing agent. It acts as a nitric oxide donor, increasing intracellular cyclic guanosine monophosphate (cgmp), which effects relaxation of vascular smooth muscle in both arterioles and veins. The overall effect is a decrease in atrial filling pressure and svr with a concomitant increase in cardiac output. The vasodilatory effects of nitroprusside occur within minutes with intravenous administration. The principal metabolites of sodium nitroprusside are thiocyanate and cyanide. Thiocyanate toxicity is unusual in children with normal hepatic and renal function, and monitoring of cyanide and thiocyanate concentrations in children may not be correlated with clinical signs of toxicity. In neonates with low cardiac output, there may be an increase in urine output and an improvement in perfusion with institution of nitroprusside, but there can also be a significant drop in blood pressure necessitating care in its use.